Dr. David Tribble

Offering Hospice as an Option

No one likes a quitter.

Too often that seems to be the sentiment when it comes to calling a halt to ‘curative’ treatments and accepting hospice care. Yet, evidence-based research doesn’t mirror the attitude that often filters down from physician to patient. (See related story below.)

“If you talk to most patients … and indeed many physicians … about hospice care, their first reaction is ‘I’m not ready to give up,’” said David B. Tribble, MD, FAAFP, chief medical officer for Alive Hospice.

“Their image is of putting the Eskimo on the ice floe and pushing them out to the North Pacific. That’s the reason we have trouble with hospice adoption because it is seen as abandoning the patient, but nothing could be further from the truth,” Tribble stated. Instead, he continued, adopting palliative care and hospice services embraces the needs of the patient.

Evidence is beginning to show that following ‘usual treatment’ past a certain point rarely buys a person much additional time or quality of life. When a patient fighting cancer has failed first and second lines of treatment, the effectiveness of a third line of chemotherapy is in the single digits and immeasurable in the fourth line, according to Tribble. “At that point, the important thing to remember is curative care is no longer curative.”

While hospice and palliative care are board certified specialties, it hasn’t been too long ago when the concept was still foreign in mainstream medicine. Tribble recalled that during his time in medical school during the 1970s, physicians typically didn’t share a terminal diagnosis with a patient. “Doctors had this odd notion that if you told the patient their diagnosis, the patient would just give up and not fight,” said Tribble, who is double board certified in family medicine and in hospice and palliative medicine.

A case that particularly resonated with him during med school was a single mother diagnosed with acute myelogenous leukemia. At that time, he said, the diagnosis usually meant death within a number of weeks. Knowing that the patient needed to make arrangements for her young child, Tribble told her the prognosis. “I got in trouble for that, but it got me interested (in hospice medicine),” he noted. “I’ve been involved since that time with what was then called the ‘Death with Dignity’ movement.”

Despite increasing awareness regarding hospice and palliative care, Tribble said he still sees the concept being introduced too late or not at all. “In 30-plus years of practice, I’ve seen all types of treatments inflicted on patients that everyone in the room knew weren’t going to work.”

Recognizing that medical advances are made through clinical trials and experimental treatments, Tribble said patients should have all the facts to make the right decision for themselves and their families. Making that decision, however, requires a thoughtful conversation outlining options and facts.

The first consideration is whether or not a patient is eligible for hospice services. To qualify for the hospice benefit under Medicare … and by extension through most commercial carriers … a patient must have a diagnosis that deems likely survival of six months or less if the disease runs its normal course. Patients also agree to stop seeking curative treatments for the terminal diagnosis and instead opt for palliative measures. It is a misconception, however, that patients cannot continue curative measures or chronic disease management steps for other health conditions outside of the terminal diagnosis. A diabetic, for example, with end-stage congestive heart failure would still be allowed to take insulin.

Of course, some patients outlive the six-month timeframe, but hospice benefits can be renewed, as long as the patient still has an illness from which death in six months is usual.” In fact, survival is often longer in hospice care than when pursuing usual therapy.

When initiating a discussion about a terminal diagnosis and hospice care, Tribble said the first step is to ask the patient how they are. “You don’t start off by telling. You start off by asking … but the next part is equally important, and that is you have to be quiet long enough to hear the answer,” he counseled.

Sometimes, physicians are surprised to find how much patients already know or suspect. Sometimes, physicians find a patient is making decisions based on wrong information. “If a patient has inaccurate beliefs, that’s a good time to say, ‘That’s not quite right. Let me tell you where we are.’”

He continued, “Distinguish between opinion and fact and stay on fact as much as you can. ‘You’ve been on three rounds of chemo, and your cancer has continued to grow. Data on further chemo shows the likelihood of improvement is less than ‘x’ percent. I don’t think more chemo is going to help you, but there are other things we can do to make the most out of whatever time you have left.’”

Some patients simply never get to the point where they can hear and accept a terminal diagnosis. “Sometimes denial is the only mechanism they have, and we have no right to strip that away from them,” Tribble said.

“You can’t take an approach across the board to all patients,” he continued. “You have to take an approach to each patient based on knowledge of that patient.”

Tribble also cautioned that physicians be direct but compassionate in these conversations. After the ‘don’t tell’ mentality of the 1960s and 1970s, Tribble said the culture swung 180º in the 1980s. “It was almost as if physicians were grabbing every patient by the shoulder and saying, ‘Good God man, don’t you know you’re dying?’” Conversely, some physicians use so many euphemisms that the patient doesn’t actually understand what is being relayed, which can raise false hope.

Striking a happy medium between too blunt and overly optimistic is the best option, but Tribble said finding that balance is an art. In fact, he counseled physicians to truly take stock of their abilities and be honest with themselves about whether or not this is a conversation they would be comfortable having. “For some doctors, this just is not in their skill set,” he said.

If not, he continued, the best option might be to call in a palliative care specialist. There are a number of such physicians and nurse practitioners in the area willing and able to speak with patients, while still keeping the referring physician in the loop and as involved in the process as that physician chooses to be. “We likely have tricks up our sleeves they do not. We are experts in opioid analgesics, nausea control. We probably have a wider armamentarium of medicines than most physicians do. We also are trained in having the conversations that make most physicians’ palms sweaty.”

Physicians should also be aware that such conversations are time consuming, which is contrary to the country’s typical medical model. Therefore, it is critical that enough time be carved out to allow patients to absorb news, ask questions and discuss options. “It needs to be in a setting first and foremost where people don’t feel pressured, and that includes the physician. You need to sit down; you need to look people in the eye; you need to adopt the position of active listening.” He added, “It may not necessarily occur all in one appointment, and you need to know this appointment can screw up your schedule for the rest of the day if you do not plan adequately for it,” he cautioned, adding that it might be wise to plan for such an appointment at the end of the work day.

Tribble said it is also important for patients to know their options include the ability to reverse the decision on hospice care. Saying ‘no’ up front doesn’t mean a patient can’t change their mind later. Equally, if a new clinical trial uncovers a remarkable treatment option, a patient in hospice care has the right to opt out and resume curative treatment. “If you adopt this, and this is not for you for any reason, all you have to do is sign a piece of paper, and it all goes away,” he said of the hospice benefit.

Ultimately, Tribble stressed, the focus should be … as always … on providing the best evidence-based care. For many, adopting hospice services actually extends survivability and enhances the life that is left … however long that might be.

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Related Story

Research Show Hospice Care Doesn’t Shorten Life

One of the big stumbling blocks for many patients and physicians is the fear that adopting hospice care is akin to throwing in the towel and might, therefore, shorten life. The research, however, does not bear out that assumption.

David Tribble, MD, FAAFP, chief medical officer for Alive Hospice, pointed to a 2007 retrospective study in the Journal of Pain and Symptom Management (Stephen Connor, PhD, et al.) that compared survival times among specific groups of terminally ill patients who received hospice care and those who did not. For five subgroups of cancer plus congestive heart failure (CHF), the mean survival was 29 days longer for hospice patients. Breaking out CHF alone, the average survival was 88 days longer with hospice care than with usual care. In some cases, particularly terminal breast and prostate cancer, hospice care didn’t make a statistical difference in survivability. But, as Tribble pointed out, “In no case did the patients who received hospice services live any shorter length of time than those who received usual care.”

Similarly a recent study out of Massachusetts General Hospital, which was published in the August 2010 edition of the New England Journal of Medicine, also found palliative medicine makes a measurable difference in survivability and quality of life. Researchers looked at 150 patients who presented with stage 4 non-small cell lung cancer. All patients received standard treatment, but half also received palliative care. In the palliative medicine group, patients were:

• Four times more likely to have advance directives in place,
• Two times more likely to have better symptom control,
• Only one-third as likely to have received chemotherapy within a week of their death,
• Adopted hospice care earlier in the disease process, and
• Lived three months longer than their counterparts in the non-palliative care group.

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